Provider Demographics
NPI:1720682206
Name:GWINN-MACKEY, MICHELLE RENEE (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:GWINN-MACKEY
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 JASON PL
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-2018
Mailing Address - Country:US
Mailing Address - Phone:217-483-2496
Mailing Address - Fax:217-483-5772
Practice Address - Street 1:1099 JASON PL
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-2018
Practice Address - Country:US
Practice Address - Phone:217-483-2496
Practice Address - Fax:217-483-5772
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-286073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist